Employee Benefits Enrollment Form - Cheyenne Regional Medical ... 2025

1. Click ‘Get Form’ to open the Employee Benefits Enrollment Form in the editor.
2. Begin by filling out your personal information in the EMPLOYEE ENROLLMENT INFORMATION section. Include your name, Social Security Number, mailing address, and marital status.
3. Next, provide details about your dependents in the DEPENDENT INFORMATION section. Ensure you include their names, dates of birth, and specify if you are adding or deleting any dependents.
4. Complete the OTHER INSURANCE COVERAGE INFORMATION section by answering questions regarding COBRA coverage and listing any other health insurance you or your dependents have had in the past 12 months.
5. Select your desired health, dental, and vision insurance options under HEALTH INSURANCE ENROLLMENT, DENTAL INSURANCE ENROLLMENT, and VISION INSURANCE ENROLLMENT sections respectively.
6. If applicable, fill out the FLEXIBLE SPENDING ACCOUNT ENROLLMENT section to elect contributions for health and dependent care expenses.
7. Finally, review all information for accuracy before signing and dating the AUTHORIZATION section at the end of the form.

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